UK Renal Registry 18th Annual Report: Chapter 11 2014 ... · UK Renal Registry 18th Annual Report: Chapter 11 2014 Multisite Dialysis Access Audit in England, Northern Ireland and

UK Renal Registry 18th Annual Report:Chapter 11 2014 Multisite Dialysis AccessAudit in England, Northern Ireland andWales and 2013 PD One Year Follow-up:National and Centre-specific AnalysesAnirudh Raoa, Rebecca Evansa, Martin Wilkieb, Richard Fluckc, Mick Kumwendad

aUK Renal Registry, Bristol, UK; bSheffield Teaching Hospitals, Sheffield, UK; cDerby Teaching Hospitals NHS FoundationTrust, Derby, UK; dGlan Clwyd Hospital, Rhyl, UK

Key WordsChronic kidney disease . Diabetes . Dialysis . End stagerenal disease . Established renal failure . Haemodialysis .Peritoneal dialysis . Prevalence . Renal replacement therapy. Transplantation . Treatment modality . Vascular access

Summary. Data are presented from the third combined vascu-

lar and peritoneal dialysis access audit.. In 2014, 53 centres in England, Wales and Northern

Ireland (out of 62) returned data on first access from4,339 incident haemodialysis (HD) patients and1,090 incident peritoneal dialysis (PD) patients.

. Of the 5,429 incident patients, 20.1% started dialysison PD, 27.8% started with an arteriovenous fistula(AVF), 1.0% with an arteriovenous graft (AVG),27.1% on a tunnelled line (TL) and 24.0% on anon-tunnelled line (NTL).

. Older patients (565 years) were more likely to starthaemodialysis using AVF compared to theiryounger counterparts (36.2% vs. 32.8%).

. Thirteen of the nineteen centres (68%) using thephysician led percutaneous insertion technique hadover 20% of their incident patients starting on PDwhen compared to only seven out of fourteen centres(50%) which used single technique (open surgical orlaparoscopic) for their PD catheter insertion.

. Wide variations were apparent between centres foruse of AVF as the first haemodialysis access rangingfrom 10–54%.

. Eight of the 49 centres were achieving close to the65% target for AV fistula in their incident patients.

. Length of time known to nephrology services andlikelihood of commencing dialysis using either anAVF or a PD catheter are strongly associated.Patients who were known to a nephrologist forover one year were more likely to start dialysiswith AVF, as compared to those who were referredbetween 90–365 days (39.2% vs. 24.6%). Similarly,patients who were known to a nephrologist between90 days and one year were more likely to start on PDwhen compared to patients who were referred ,90days prior to dialysis start (26.9% vs. 9.1%). By com-parison, amongst the late presenters, only 3.5% hadfirst access documented as an AVF and 87.3%started dialysis on either a tunnelled line or a non-tunnelled line.

. Initial surgical assessment was a key determinant ofthe likelihood of AVF formation. Of the incidentpatients known to renal services for longer thanthree months and in those assessed by a surgeon atleast three months prior to starting dialysis, 71.4%started dialysis with an AVF whereas of those whowere not seen by a surgeon only 10.8% did.

. Thirty one of the 38 centres were 2 or 3 standarddeviations below the 85% target for prevalent haemo-dialysis patients with an AV fistula.

. For centres returning data on one-year peritonealdialysis outcomes, the majority of centres (28/32)maintained 550% of patients on PD at one year,having censored for transplantation.

. This report demonstrates wide variations in practicebetween centres across several domains in theprovision of dialysis access and further work willbe required to understand the underlying reasons.

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# 2016 The UK Renal RegistryPublished by S. Karger AG, Basel1660–8151/16/1325–0253$39.50/0

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Anirudh RaoUK Renal Registry, Southmead Hospital, Southmead Road,Bristol, BS10 5NB, UKEmail: [email protected]

Nephron 2016;132(suppl1):253–278DOI: 10.1159/000444825

Published online: April 19, 2016

Introduction

High quality vascular access is a key modifiable riskfactor for patients on dialysis and is an importantmeasure of good clinical care. The third combined vascu-lar and peritoneal dialysis access audit in England, Walesand Northern Ireland represents the findings from the2014 data collection period for patients starting dialysisbetween 1st January 2014 and 31st December 2014.The combined access audit provides information ontimely and appropriate access interventions in order toachieve permanent access based on the recommendationsand quality requirements stated in Renal Associationclinical practice guidelines and vascular access guidelinesfor haemodialysis and peritoneal access [1, 2]. The coreprincipal of these audits has been to highlight theperformance variation of renal centres across England,Wales and Northern Ireland and explore factors thatmay contribute to the provision of excellent quality vas-cular and peritoneal access.

The term established renal failure used within thischapter is synonymous with the terms end stage renalfailure and end stage kidney disease, which are in morewidespread international usage. Patients have dislikedthe term ‘end stage’, which reflects the inevitable outcomeof this disease.

Methods

All adult renal centres in England, Wales and Northern Irelandwere contacted regarding vascular and peritoneal access for allincident and prevalent dialysis patients (centre level only) in2014. Data were collected using Microsoft Excel spreadsheets cir-culated by the UK Renal Registry (UKRR).

The records were also validated against the UKRR database toconfirm that the population collected at each centre for the auditwas the same as, or representative of, the incident population atthat centre as collected via the usual UKRR quarterly return.Data checks were made by cross-referencing with the UKRR data-base. Any patients identified from the UKRR as not incident todialysis between 1st January 2014 and 31st December 2014 wereexcluded. Patients were categorised as having AKI for the purposesof this audit and therefore excluded if they did not match to UKRRdata and their access at three months was recorded as recoveredrenal function or not recorded. Similarly, where the reportedprevalent numbers from the audit were more than 10% differentto those in the UKRR database, those centres were excluded.The cross-referencing also enabled ascertainment of informationon mortality within three months of commencing dialysis.

Centres who reported data on peritoneal dialysis (PD) patientsin the 2013 vascular and peritoneal access audit were asked to

complete a one year follow up of their PD patients. Additionalinformation was requested on the date of PD catheter failure,the reason for catheter failure, the number of catheters used duringthe year, and the modality in use at one year after starting PD.

Table 11.1 lists the summary of audit measures as stated in theRenal Association clinical practice guidelines, with explanation forwhy some of the audit measures were not reported.

Patients starting haemodialysis (HD) were grouped by type offirst vascular access: arteriovenous fistula (AVF), arteriovenousgraft (AVG), tunnelled dialysis line (TL), non-tunnelled dialysisline (NTL). Patients starting PD were categorised by the insertiontechnique: laparoscopic, peritoneoscopic, open surgery, percuta-neous. Access at three months was defined as the type of accessin use at three months after starting dialysis. If a patient was nolonger receiving dialysis at three months then the reason wasrecorded instead, for example died or transplanted. Referral timewas defined as the number of days between the date of firstbeing seen by a renal physician and the date of commencingdialysis. A patient was classified as presenting late if they had areferral time of less than 90 days. In the analyses involving whetheror not a patient had received surgical assessment at least threemonths before starting dialysis, patients were excluded if theywere categorised as a late presenter.

Access failure was defined as the access no longer being usablefor dialysis. Data about the date and cause of access failure was col-lected. For the purposes of analysis, access failures were groupedinto five groups (maturation, mechanical, infection, other andunknown) for HD failures and six groups (infection, catheterrelated, solute/water clearance, leaks/hernia, other and unknown)for PD failures. Those grouped into ‘other’ included conservativemanagement, dialysis withdrawn and line replaced. Access failurewas censored for death, transplantation, withdrawal from renalreplacement therapy (RRT) and elective switching of access type.It was the intention to only capture access failures relating to thefirst type of access. If the reason recorded for access failure wasnot related to the first type of access recorded, then the data wasnot included in this analysis.

Separate and combined analyses have been performed forincident HD patients and incident PD patients as appropriate.Due to the exploratory nature of the audit the analyses havebeen limited to descriptive statistics of frequencies, percentagesand unadjusted associations between variables. If a centre hadmore than 50% missing returns for a particular data field, thenall patients from that centre were excluded from analyses involvingthat data field. The data were analysed using SAS 9.3.

Results

Inclusion and exclusion criteriaFigure 11.1 is a flow diagram of exclusions. Of the 62

centres contacted, data were received from 54 centres.In the three years of the running of the combinedaudit, three centres have not contributed data (Carshal-ton, Coventry, Kent) with three centres having contribu-ted only once (Bristol, Dudley, London Guys). Only one

254 Nephron 2016;132(suppl1):253–278 Rao/Evans/Wilkie/Fluck/Kumwenda

centre was excluded due to poor data quality (Ipswich).Patients (n = 558) who did not match when cross-refer-encing with the UKRR database and whose access at threemonths was ‘recovered renal function’ were categorisedas having AKI for the purposes of this audit and excluded.Fifteen patients were excluded from all analyses due tomissing RRT start date or first access type.

Data completenessFifty-three centres returned data on first dialysis access

for 4,339 incident HD patients and 1,090 incident PDpatients. The UKRR incident patient data for the sameyear were 4,895 HD and 1,396 PD, thus there were accessreturns on 88.6% of HD and 78.1% of PD patients. Thepatient demographic returns via the access audit corre-lated well with the data returns made via the usualUKRR quarterly returns. The completeness of allvariables in the audit was over 80% apart from bodymass index (BMI) which was 54.3% (data not shown).

Variations in first dialysis accessPatient demographicsThe median patient age when starting RRT was 68

years in the HD cohort and 61 years for patients com-mencing PD. Overall, 63.7% of the patients were male,36.3% female; the proportional distribution of the sexeswas similar for both the HD and PD subgroups.

A significant proportion of patients starting dialysishad diabetes (53.6%), however diabetes associatednephropathy was the primary renal disease (PRD) inonly 26.2% (table 11.2).

Table 11.3 presents HD and PD patient subgroupsstratified by age, dichotomised body mass index (BMI)(430 or .30), PRD, referral time (,90 or 590 days)and surgical assessment status.

There was an association between the access modality(HD vs. PD), referral time (,90 days vs. 590 days) andsurgical assessment status in excess of three months priorto dialysis start. The following observations can be made:

Table 11.1. Summary of audit measures stated in Renal Association clinical practice guidelines for dialysis access

RA audit measure/guideline Reported Reason for non-inclusion

HD access

1 Proportion of patients whose first haemodialysis treatment is with an arteriovenousfistula:

Yes

1a Stratified by new patients with established renal failure and known to thenephrology team for .90 days

Yes

1b Stratified by new patients with established renal failure and known to thenephrology team for 490 days

Yes

1c Patients with a failed renal transplant No Not captured by the audit1d Patients transferred permanently from PD to haemodialysis No Not captured by the audit2 65% of all patients commencing haemodialysis should commence with an AV fistula Yes3 A centre should measure the proportion of prevalent long term haemodialysis

patients receiving dialysis via a fistula, an arteriovenous graft and a tunnelled or anon-tunnelled line

Yes

4 85% of all prevalent patients on haemodialysis should receive dialysis via afunctioning arteriovenous fistula

Yes

5 Complications related to vascular access Yes5a Rupture of vascular access (fistula and graft) Partly Incident patients only

PD access

1 Catheter patency – more than 80% of catheters should be patent at 1 year(censoring for death and elective modality change)

Yes

2 Complications following PD catheter insertion: Partly2a Bowel perforation ,1% No Not captured by the audit2b Significant haemorrhage ,1% No Not captured by the audit2c Exit site infection within 2 weeks of catheter insertion ,5% No Not captured by the audit2d Peritonitis within 2 weeks of catheter insertion ,5% Yes2e Functional catheter problem requiring manipulation or replacement or leading to

technique failure ,20%No Not captured by the audit

Multisite dialysis access audit Nephron 2016;132(suppl1):253–278 255

For HD:

. AVF was the initial access for 34.8% of patients, with1.2% with an AVG, 34.0% on a tunnelled line and30.0% on a non-tunnelled line. The percentage ofpatients starting with an AVF had been stable forthe previous three years but has since fallen from40.7% in 2013. The majority of centres are failingto achieve the target as stated in the Renal Associ-ation guidelines (65% of all patients commencinghaemodialysis should commence with an AVF).

. Patients aged 65 or over were more likely to startRRT with an AVF (36.2%) when compared topatients ,65 years (32.8%). Similarly, older patientswere less likely to start on a tunnelled line (30.3% vs.38.7%).

. BMI had a positive impact on vascular access with48.9% of the patients with BMI .30 starting on AVFcompared to 36.8% of the patients with BMI 430.

. Patients with polycystic kidney disease (PKD) asprimary renal diagnosis were most likely to startwith an AVF (66.1%).

. Patients, who were referred at least 90 days prior tocommencing dialysis, were more likely to start onAVF compared to those starting more acutely(48.4% vs. 3.8%).

. A high proportion of patients who were referred atleast 90 days prior to commencing dialysis, start

Total number of incident patients in dialysis access audit 6,072

(54 centres)

Total number of patients in dialysis access audit data 6,002

(53 centres)

Total number of incident patients in dialysis access audit data 5,444

(53 centres)

70 patients (1 centre) excluded due to poor quality data

15 patients excluded as missing access at start

Total number of patients in analysis 5,429 (53 centres)

558 patients excluded as they did not match to UKRR data and their access at 3 months was recovered

renal function

Fig. 11.1. STROBE flow diagram of exclusions

Table 11.2. Patient demographics

Total HD PDVariable N = 5,429 N = 4,339 N = 1,090

Age Median (IQR) 66 (53, 76) 68 (55, 77) 61 (48, 72)

BMI Median (IQR) 27 (24, 32) 27 (24, 32) 27 (24, 31)

N (%) N (%) N (%)Gender Female 1,972 (36.3) 1,588 (36.6) 384 (35.2)

Male 3,457 (63.7) 2,751 (63.4) 706 (64.8)

Diabetes Missing 625 (11.5) 528 (12.2) 97 (8.9)Yes 2,908 (53.6) 2,267 (52.2) 641 (58.8)No 1,896 (34.9) 1,544 (35.6) 352 (32.3)

PRD Missing 247 (4.5) 202 (4.7) 45 (4.1)Diabetes 1,423 (26.2) 1,124 (25.9) 299 (27.4)Glomerulonephritis 624 (11.5) 448 (10.3) 176 (16.1)Hypertension 324 (6.0) 261 (6.0) 63 (5.8)Other 1,090 (20.1) 957 (22.1) 133 (12.2)Polycystic kidney 243 (4.5) 165 (3.8) 78 (7.2)Pyelonephritis 264 (4.9) 225 (5.2) 39 (3.6)Renal vascular disease 347 (6.4) 283 (6.5) 64 (5.9)Uncertain 867 (16.0) 674 (15.5) 193 (17.7)

IQR = interquartile range; BMI = body mass index; PRD = primary renal diagnosis; HD = haemodialysis; PD = peritoneal dialysis


dialysis on a tunnelled (32.6%) or a non-tunnelled(17.3%) line.

. Patients who had been seen by a surgeon at leastthree months before starting dialysis were morelikely to start with an AVF than those not assessed(70.2% vs. 5.6%).

For PD:

. For 1,090 first PD catheters, the insertion techniqueswere 38.1% open surgical, 18.1% laparoscopic, 1.8%peritoneoscopic and 28.3% percutaneous. Insertiontechnique was not reported for the remaining 13.7%.

. There was a greater proportion of patients whounderwent percutaneous PD catheter insertion inthe BMI 430 group in comparison with thosewith BMI .30 (22.7% vs. 14.9%).

. Referral time had an influence on PD catheter inser-tion technique; 38.6% of patients referred less than90 days before starting dialysis underwent percuta-neous insertion compared to 27.0% of patientsknown longer to the service. These data werereversed for general surgical insertion: 26.0% ofpatients who presented late versus 39.7% of patientswho did not present late.

. Patients who were assessed by a surgeon at leastthree months before starting dialysis were morelikely to undergo open surgical placement (39.3%vs. 29.6% for non-surgical assessment).

Figure 11.2 shows haemodialysis access stratified byPRD. The proportional distribution of PD access wasreasonably similar for different primary renal disease

Table 11.3. Patient characteristics stratified by type of first dialysis access

VariableHDN

HD patients

PDN

PD patients

AVF AVG TL NTLOpen

surgeryLaparo-scopic

Peritoneo-scopic

Percuta-neous Missing

Total patients 4,339 1,508 54 1,474 1,303 1,090 415 197 20 309 149% 34.8 1.2 34.0 30.0 38.1 18.1 1.8 28.3 13.7

Age at first dialysis % %

,65 1,889 32.8 1.2 38.7 27.3 640 38.3 18.1 2.2 28.6 12.8565 2,450 36.2 1.3 30.3 32.2 450 37.8 18.0 1.3 28.0 14.9

BMI (kg/m2)430 1,403 36.8 1.9 36.3 25.1 423 43.7 14.9 3.8 22.7 14.9.30 745 48.9 1.3 29.4 20.4 161 49.1 18.0 1.9 14.9 16.1No BMI 605 18.5 1.0 29.6 50.9 84 44.0 20.2 1.2 23.8 10.7

PRDDiabetes 1,124 40.9 1.3 37.5 20.2 299 36.5 18.4 1.7 29.1 14.4GN 448 34.2 0.4 41.5 23.9 176 39.8 19.9 2.8 27.8 9.7Hypertension 261 50.6 0.8 28.4 20.3 63 33.3 17.5 1.6 34.9 12.7No PRD 202 17.8 0.5 33.2 48.5 45 31.1 8.9 0.0 40.0 20.0Other 957 15.7 0.8 30.8 52.7 133 35.3 21.1 1.5 24.1 18.0PKD 165 66.1 3.0 26.1 4.8 78 56.4 19.2 1.3 14.1 9.0Pyelo 225 41.3 2.2 33.3 23.1 39 35.9 20.5 2.6 25.6 15.4RVD 283 38.2 1.1 31.1 29.7 64 43.8 9.4 3.1 28.1 15.6Uncertain 674 39.6 1.9 33.2 25.2 193 35.2 18.1 1.6 32.1 13.0

Referral time (days),90 1,275 3.8 0.2 37.3 58.7 127 26.0 22.0 1.6 38.6 11.8590 3,002 48.4 1.7 32.6 17.3 962 39.7 17.6 1.9 27.0 13.8No ref 62 8.1 1.6 32.3 58.1 1 0.0 0.0 0.0 0.0 100

Assessed by surgeonMissing 59 25.4 0.0 42.4 32.2 81 66.7 13.6 0.0 18.5 1.2No 2,290 5.6 0.5 44.8 49.1 439 29.6 14.1 2.5 41.2 12.5Yes 1,910 70.2 2.0 21.2 6.7 557 39.3 22.3 1.6 20.3 16.5

Patients from centres with more than 50% missing data for a variable are excluded from the table for that variableAVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line; GN = glomerulonephritis; BMI =body mass index; PRD = primary renal diagnosis; PKD = polycystic kidney disease; Pyelo = pyelonephritis; RVD = renal-vascular disease


but varied for HD access modality. Of note, patients withpolycystic kidney disease were more likely to start HDwith an AVF (66.1%). Where no primary renal diagnosiswas available, patients were more likely to start dialysiswith a non-tunnelled dialysis venous catheter (48.5%).

Figure 11.3 shows the distribution of haemodialysisaccess modality and PD catheter insertion technique stra-tified by BMI. As noted in table 11.2, unexpectedly BMIhad a positive impact on type of vascular access withonly 49.8% of the patients with BMI .30 kg/m2 startingon a catheter compared to 61.4% of the patients with BMI430 kg/m2. In relation to peritoneal dialysis access,

patients with BMI .30 kg/m2 were more likely toundergo open surgical placement (58.5%) than thosewith BMI 430 kg/m2 (51.4%). The percutaneousapproach was less likely to be used in patients in thehigher BMI category (17.8%) compared to those with alower BMI (26.7%). The peritoneoscopic or laparoscopicapproach was used in a similar proportion of patients inboth BMI groups. It should be noted that the analysis waslimited due to a high proportion of missing data for BMI.

Figure 11.4 shows PD catheter insertion technique bycentre. Centres reporting less than five patients on PDwere not considered for analysis (n = 8). Seven centres

PKD (165)

Hypertension (261)

Pyelonephritis (225)

Diabetes (1,124)

Uncertain (674)

RVD (283)

GN (448)

No data (202)

Other (957)

Prim

ary

rena

l dia

gnos

is

0 20 40 60 80 100Percentage of patients

AVFAVGTLNTL

Fig. 11.2. Type of haemodialysis access stratifiedby primary renal diseaseNumber of patients in each primary renal diagnosisgroup in bracketsPrimary renal diagnosis groups sorted by percentage ofarteriovenous fistulaAVF = arteriovenous fistula; AVG = arteriovenousgraft; TL = tunnelled line; NTL = non-tunnelled line;GN = glomerulonephritis; RVD = reno-vasculardisease; PKD = polycystic kidney disease

BMI group

0

20

40

60

80

100

<30(1,403 patients)

>30(745 patients)

HD

<30(360 patients)

>30(135 patients)

PD

Perc

enta

ge o

f pat

ient

s

PercutaneousPeritoneoscopicLaparoscopicOpen surgery

AVFAVGTLNTL

Fig. 11.3. Distribution of haemodialysis access modality and PD catheter insertion technique stratified by body mass indexBMI = body mass indexAll patients from centres with more than 50% missing data for BMI were excludedAVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line



Cent

re

Basldn (10)

Belfast (5)

Cardff (27)

Hull (22)

Leeds (23)

Newc (25)

Swanse (16)

York (14)

Sheff (26)

Nottm (24)

Dorset (19)

L St.G (13)

Ports (35)

Liv Ain (14)

Prestn (27)

Bangor (6)

Oxford (42)

Donc (9)

M RI (37)

Redng (32)

Stevng (13)

Brightn (30)

L Barts (91)

Stoke (33)

Liv Roy (19)

B QEH (56)

Wolve (30)

L Rfree (68)

Carlis (15)

Chelms (17)

Middlbr (9)

Shrew (21)

Sund (8)

Wrexm (9)

Wirral (5)

Camb (13)

Salford (36)

Plymth (10)

Leic (47)

Derby (29)

B Heart (14)

Exeter (28)

L Kings (9)

L West (23)

Sthend (12)

Total (1,090)

Open surgeryLaparoscopicPeritoneoscopicPercutaneousNo data

Fig. 11.4. PD catheter insertion technique stratified by centre


reported less than five patients using PD catheters for firstdialysis in 2013. There continues to be a strong tendencyfor many centres to rely on one single approach to PDcatheter placement, with 15 centres reporting use of a singletechnique for all of their patients mainly open surgical orlaparoscopic. Two centres (Birmingham Heartlands,Southend) used percutaneous technique close to all oftheir PD catheter insertions with a further two centres(Derby, Wolverhampton) employing this technique inabout 90% of cases. Fifteen other centres reported usingthe physician led percutaneous insertion technique. Thir-teen of the nineteen centres (68.4%) using the physicianled percutaneous insertion technique had over 20% oftheir incident patients starting on PD with three centres(Southend, Derby, Wolverhampton) having close to 40%of their incident patients starting on PD. By comparisononly seven out of fourteen centres (50.0%) using singletechnique (open surgical or laparoscopic) had over 20%of their incident patients starting on PD (figure 11.5).

First dialysis access by renal centreFigure 11.5 shows type of first dialysis access by centre.

Approximately a quarter of the patients started with anAVF (27.8%) with over half of patients starting with aTL or NTL (51.2%) with approximately a 50–50 splitbetween the two access types. Variations were apparentbetween centres when considering patients commencingdialysis via an AVF, ranging from ,15% (London West,Carlisle) to .50% (Doncaster, Clwyd). Some centres hadover 50% of patients starting dialysis on a tunnelled line(London West, Colchester). The use of arteriovenousgraft as the first dialysis access was between 0–11 percentwith only 21 of the 53 centres opting to use this.

Use of a PD catheter as first access varied between.40% (Derby, Southend) and 0% (Clwyd).

The Renal Association (RA) guidelines on vascularaccess for haemodialysis recommends 65% of all patientscommencing haemodialysis should commence with anAV fistula. This is depicted in figure 11.6 with patientswho presented late excluded for this analysis. Eight ofthe 49 centres (Chelmsford, York, Basildon, Derby, Liver-pool Aintree, Doncaster, Stoke, Sheffield) reportingincident vascular access data were achieving close to theRA recommendations (.60%) with one centre achievingabove 2 standard deviations (Stoke). However, there were12 centres below 2 standard deviations and a further 15centres below 3 standard deviations. These centres canbe identified using figure 11.11. The results have to becautiously interpreted due to non-adjustment for anypatient related factors.

First dialysis access and referral timeFigure 11.7 shows a clear association between time

known to a nephrologist and a patient starting haemo-dialysis with an AVF. A greater proportion of patientswho were known to a nephrologist for over one yearstarted dialysis with an AVF, as compared to those whowere referred between 90–365 days (39.2% vs. 24.6%).Similarly, patients who were known to a nephrologistbetween 90 days to one year were more likely to starton PD when compared to patients who were referred,90 days prior to dialysis start (26.9% vs. 9.1%).

Figure 11.8 shows PD catheter insertion technique byreferral time. Patients who were first seen by a nephrolo-gist ,90 days before starting RRT were more likely toundergo percutaneous insertion when compared topatients who were known between 90–365 days and.365 days (38.6% vs. 32.8% vs. 25.6%). These resultsmay be due to centre effect and a reflection of practicepatterns within the centre. Of the 13 centres that usedthe percutaneous insertion technique for over 50% oftheir PD catheters, five (Derby, London Barts, Man-chester Royal Infirmary, Stoke, Wolverhampton) hadover 20% of their patients presenting late starting onPD (figures 11.4 and 11.10). Open surgical techniquewas less likely to be used in the patients presenting latewhen compared to the patients who were known over365 days, probably because of having a lesser likelihoodof seeing a surgeon (26.0% vs. 40.2%).

Figure 11.9 shows first access for centres providingdata for patients presenting to a nephrologist 590 daysprior to dialysis start. Amongst the 4,027 patients, only36.2% started with an AVF, below the Renal Associationtarget and 23.9% started with a PD catheter. Despitebeing known to a nephrologist for over three months38.6% of the patients started on a TL or NTL. As illus-trated in figure 11.9 there was a significant variationbetween centres.

Figure 11.10 shows first access for centres providingdata for patients presenting late (known to renal servicesfor ,90 days). Amongst the 1,402 patients for whom datawere reported, 33.9% started dialysis on a tunnelled line,53.4% on a non-tunnelled line and 9.1% using a PDcatheter with only 3.5% having first access documentedas an AVF.

In nine centres, more than 15% of patients presentinglate had a peritoneal dialysis catheter inserted for use asfirst dialysis access and as a result had a lower require-ment for tunnelled or non-tunnelled lines. The overallproportion of patients presenting late starting with anAVF for all of the centres was 3.5%. Three centres



Cent

re

Sthend (26)Derby (66)Carlis (39)

Wolve (81)Chelms (47)

L Rfree (207)Shrew (64)

L Barts (281)Stoke (102)

M RI (129)Bangor (21)

Redng (117)York (53)

Nottm (91)Basldn (39)

Hull (87)Salford (146)

Newc (103)B QEH (236)

Oxford (180)Dorset (85)Liv Roy (87)

Leic (220)Liv Ain (67)

Brightn (153)Exeter (148)Plymth (54)Cardff (150)West NI (17)

Ports (200)Prestn (157)

Sheff (155)Ulster (24)

Leeds (139)B Heart (87)

Donc (56)Wrexm (61)

Sund (56)L St.G (93)

Newry (22)Camb (101)

Swanse (150)Wirral (49)

Middlbr (90)Stevng (168)L Kings (117)

Belfast (69)L West (320)

Truro (52)Antrim (35)Bradfd (72)Clwyd (21)Colchr (39)

Total (5,429)

PD catheterAVFAVGTLNTL

Fig. 11.5. Type of first dialysis access stratified by centreCentres are ordered by the percentage of patients starting dialysis with a PD catheterPD = peritoneal dialysis; AVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line


however had over 15% of the patients who presented latestarting with an AVF (Shrewsbury 27.5%, Colchester20.0%, Derby 17.6%). This could be explained by amultitude of factors ranging from surgical access assess-ment and formation to ongoing evaluation of an AVFto enhance maturation and earlier cannulation. Thenumber of patients presenting late reported in somecentres was extremely small and it is difficult to makefirm observations about clinical pathways for thedevelopment of dialysis access in this cohort.

Figure 11.11 shows the type of haemodialysis access inpatients known to the renal service for at least 90 days.There was variation for patients starting haemodialysiswith an AVF, with five centres (Ulster, Stoke, Doncaster,York, Chelmsford) achieving 65% or over with LondonWest and Shrewsbury at the other end at ,20%. Thecentres with highest tunnelled line use were LondonWest (72.7%), Colchester (67.6%) and Carlisle (66.7%)

with over twice the overall proportion of all the centrescombined (32.6%). There were eleven centres whoreported over 30% of patients as starting on non-tunnelled lines despite being known to the centre for atleast 90 days (Shrewsbury (40.0%), London St Georges(39.2%), Belfast (48.8%), London Kings (34.9%), Wrex-ham (33.3%), Wirral (33.3%), Reading (38.8%), Antrim(37.5%), Manchester Royal (32.7%), Swansea (32.0%),York (30.4%)). It will be important to understand thevariations in practice patterns that lie behind thesestatistics, which were not provided by current data.

First dialysis access and surgical assessmentFigure 11.12 highlights the proportion of patients

referred for surgical assessment at least three monthsprior to starting dialysis. There was considerable

100

80

60

40

20

00 50 100 150 200

Number of HD patients at centre

Perc

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Dotted lines show 99.9% limitsSolid lines show 95% limits

Fig. 11.6 Funnel plot of the percentage of HD patients who com-menced dialysis using an AVF

0

10

20

30

40

50

60

<90days 90–365 days >365 daysReferral time

Perc

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ient

s

NTLTLPD catheterAVFAVG

Fig. 11.7. Type of first dialysis access by referral timeNTL = non-tunnelled line; TL = tunnelled line; PD = peritoneal dialysis;AVF = arteriovenous fistula; AVG = arteriovenous graft

0 10 20 30 40 50 60 70 80 90 100

365+ days (776 patients)

<90 days (127 patients)

90–365 days (186 patients)

Percentage of patients

Refe

rral

tim

e

Open surgeryLaparoscopicPeritoneoscopicPercutaneousMissing PD tech

Fig. 11.8. PD catheter insertion techniqueby referral time


0 20 40 60 80 100

Sthend (17)Shrew (13)Derby (49)Carlis (29)

Chelms (37)Wolve (70)

L Rfree (161)L Barts (197)

York (36)Redng (75)

M RI (78)Stoke (82)

Salford (114)Bangor (20)

Newc (84)Basldn (34)

Hull (59)Dorset (66)Nottm (80)

Oxford (137)B QEH (174)Liv Ain (52)

Leic (179)West NI (12)Exeter (106)Brightn (98)Liv Roy (70)Prestn (108)Wrexm (39)Plymth (42)Leeds (105)Cardff (132)Sheff (118)

Sund (42)Donc (48)

Ports (162)Newry (17)

Swanse (90)B Heart (85)

Wirral (28)L St.G (86)Camb (79)

Stevng (110)Belfast (46)

Truro (28)Middlbr (68)

Ulster (10)L West (227)L Kings (95)Antrim (26)Bradfd (53)Clwyd (20)Colchr (34)

Total (4,027)

Cent

re


PDAVFAVGTLNTL

Fig. 11.9. Type of access used for first dialysis in patients presenting to a nephrologist 590 days prior to dialysis startPD = peritoneal dialysis; AVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line


0 20 40 60 80 100

Stoke (20)Derby (17)Wolve (11)Shrew (51)L Barts (84)

M RI (51)Ulster (14)

Hull (28)L Rfree (46)

L St.G (7)Redng (42)

Ports (38)B QEH (62)

Liv Roy (17)Sthend (9)

Brightn (55)Carlis (10)Camb (22)

Middlbr (22)Nottm (11)

Plymth (12)Oxford (43)

York (17)Sheff (37)

Leic (41)Exeter (42)Wirral (21)Prestn (49)

Salford (32)Leeds (34)

Swanse (60)L West (93)Antrim (9)Basldn (5)

Belfast (23)Bradfd (19)Cardff (18)

Chelms (10)Colchr (5)

Donc (8)Dorset (19)L Kings (22)Liv Ain (15)

Newc (19)Newry (5)

Stevng (58)Sund (14)Truro (24)

West NI (5)Wrexm (22)Total (1402)

Cent

re


PDAVFAVGTLNTL

Fig. 11.10. Type of access used for first dialysis in patients presenting to a nephrologist ,90 days prior to dialysis startPD = peritoneal dialysis; AVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line


Ulster (9)Stoke (56)Donc (39)York (23)

Chelms (20)Sheff (94)

Derby (25)Liv Ain (38)Basldn (24)Exeter (80)

Swanse (75)Bangor (14)Prestn (83)Leeds (83)Clwyd (20)Camb (68)

Nottm (57)Antrim (24)

Wirral (24)Wrexm (30)

Hull (42)Oxford (98)Salford (79)B QEH (126)

Leic (134)Dorset (47)

Brightn (74)Newry (14)Sthend (6)

Bradfd (49)Wolve (43)Ports (132)

Cardff (105)Middlbr (61)B Heart (72)

L Rfree (100)Redng (49)

M RI (52)Truro (25)Sund (34)Newc (59)

L Barts (125)Liv Roy (53)Stevng (97)Belfast (41)L Kings (86)West NI (9)L St.G (74)

Colchr (34)Plymth (33)

Carlis (15)L West (205)

Shrew (5)Total (3,064)

Cent

re


AVFAVGTLNTL

Fig. 11.11. Type of first access for haemodialysis patients stratified by centre restricted to patients known at 590 days prior to dialysis startAVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line


variation between the renal centres. Overall, the pro-portion referred to a surgeon was highest in Ulster(100%), Wrexham (87.2%), Bangor (85.0%), Carlisle(82.8%) and Doncaster (81.3%). This usually resulted ina high proportion of patients starting with either anAVF or PD catheter. Carlisle had only 13.8% startingwith an AVF but had 48.3% starting on PD (refer tofigure 11.9). Conversely, some centres despite having

low rates of surgical assessment, performed well ontheir PD catheter rates (figure 11.9) as they utilised per-cutaneous PD catheter insertion technique (figure 11.4).For example, three of the centres with lowest surgicalassessment, Derby (36.7%), London Barts (27.9%) andSouthend (11.8%) all achieved high PD rates in theirpatients who were known to the centre for over threemonths (Derby 49.0%, Southend 64.7%, London Barts36.5%) as these centres utilised percutaneous PD catheterinsertion technique (Derby 89.7%, Southend 91.7%,

0 20 40 60 80 100

Ulster (10)Wrexm (39)Bangor (20)

Carlis (29)Donc (48)

Basldn (34)B QEH (174)

Sheff (118)Antrim (26)Cardff (132)Liv Roy (70)

Stoke (82)Prestn (108)

Sund (42)M RI (78)Hull (59)

Stevng (110)Liv Ain (52)Shrew (13)Wolve (70)

West NI (12)Middlbr (68)Leeds (105)Colchr (34)Newc (84)

York (36)Wirral (28)

Oxford (137)Clwyd (20)Newry (17)

Leic (179)Ports (162)Truro (28)

Bradfd (53)L Kings (95)

L West (227)Exeter (106)

Camb (79)Nottm (80)Belfast (46)

Chelms (37)L Rfree (161)Salford (114)

Dorset (66)Brightn (98)B Heart (85)Swanse (90)

Redng (75)Derby (49)

L Barts (197)Sthend (17)Plymth (42)Total (3,941)

Cent

re


AssessedNot assessedNo data

Fig. 11.12. Proportion of patients undergoing surgical assess-ment more than three months prior to starting dialysis

0

20

40

60

80

100

Yes(424 patients)

No(323 patients)

Assessment by surgeon at least three months before starting PD

Perc

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PercutaneousPeritoneoscopicLaparoscopicOpen surgery

Fig. 11.13. PD catheter insertion technique stratified by surgicalassessment

0

20

40

60

80

100

Yes(1,823 patients)

No(1,092 patients)

Assessed by a surgeon at least three months before starting dialysis

Perc

enta

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f pat

ient

s

NTLTLAVGAVF

Fig. 11.14. Type of haemodialysis access stratified by surgicalassessmentAVF = arteriovenous fistula; NTL = non-tunnelled line; TL = tunnelledline; AVG = arteriovenous graft


London Barts 61.5%). The end point of achieving defini-tive access (AVF or PD catheter), is being used here as asurrogate of the surgical pathway. However, the variationseen may not be solely or indeed largely down to thesurgical assessment. Firstly, a detailed understanding offactors that prevent patients from being assessed for accessin a timely fashion is required. Secondly, the variation maybe due to organisational factors e.g. if physicians insertTenckhoff catheters then patients starting on PD maynot be referred to the surgeons and therefore those centreswill show lower rates of surgical assessment for AVF in theaudit.

In the 2014 audit returns, a greater proportion ofpatients who received surgical assessment at least threemonths prior to commencing dialysis underwent opensurgical insertion (48.8% vs. 34.7%) compared to thosewho did not (figure 11.13). This figure also providesevidence that the percutaneous PD catheter insertiontechnique is utilised where surgeons have not seen thepatient, since it is surgeon independent.

Figure 11.14 demonstrates a strong relationshipbetween being assessed by a surgeon at least three monthsbefore starting dialysis and the likelihood of starting withan AVF. This relationship was much stronger than thatbetween surgical assessment and method of PD catheterplacement. This suggests that the role of surgical assess-ment was more important in relation to AVF placement.Of those assessed by a surgeon at least three months priorto starting dialysis, 71.4% started dialysis with an AVFwhereas of those who were not seen by a surgeon only10.8% did.

Dialysis access at three months after starting RRTThe type of access used three months after starting

dialysis gives an important insight into the responsive-ness of the access formation pathway. Table 11.4expresses the proportion of patients still dialysing usinga particular form of access as a percentage of the access

they originally started dialysis with. For example, 88.4%of patients starting dialysis with an AVF were still usingthis at three months and 84.3% of patients starting onPD remained on this modality at three months. Ofpatients starting dialysis via a tunnelled line, the majoritycontinued to use this form of access at three months(74.8%) and of 1,288 patients who commenced dialysisvia a non-tunnelled line, 697 (54.1%) were dialysingthrough a tunnelled line at three months with a signifi-cant proportion 22.9% (n = 295) dying within threemonths. This data suggests that obtaining definitiveaccess for HD (AVF/AVG) within three months of start-ing treatment continues to remain a big challenge.

Figure 11.15 demonstrates the differences in accessoutcomes stratified by centre. By three months, 33.2%of patients were dialysing using an AVF (range 12.8%London West to 55.6% Doncaster); 1.3% were using anAVG (0% many sites to 10.1% Nottingham); 41.2% tun-nelled lines (8.2% York to 79.2% London West); 1.0%non-tunnelled lines; 22.1% were using a PD catheter(0% Leicester to 51.6% Carlisle) and 1.2% transplanted(0% many sites to 8.1% Leeds).

Access at three months in patients referred to renalcentres ,90 days before starting dialysis was analysed.Only 45 centres were included in this analysis. Themajority (71.9%) of patients presenting late were beingdialysed using tunnelled lines at three months afterdialysis start (figure 11.16). The between centre rangewas from 21.4% in York to 98.9% at London West.Amongst patients presenting late, only 9.9% were usingan AVF at three months (individual centres rangedfrom 0% in 14 centres to 42.9% in York). PD catheterswere used by 15.5% of patients (range 0% in six centresto 44.4% in Nottingham). It is interesting to note thatin some centres late presentation was not always associ-ated with a temporary access such as a TL or a NTL, forinstance in York despite presenting late, 42.9% of theirHD patients were dialysing via AVF at three months.

Table 11.4. Type of dialysis access at three months since dialysis start stratified by first access type

Access inuse at firstdialysis (N)

Access in use at three months (%)

AVF AVG TL NTL PD catheter Transplanted Died Stopped/LTFU No data

AVF (1,494) 88.4 0.3 4.8 0.1 0.1 1.1 3.6 1.2 0.3AVG (54) 3.7 79.6 5.6 0.0 0.0 3.7 5.6 1.9 0.0TL (1,455) 9.8 0.5 74.8 0.3 3.3 0.8 7.4 2.7 0.3NTL (1,288) 6.1 0.3 54.1 2.7 5.4 0.2 22.9 7.8 0.5PD (1,082) 0.7 0.0 6.0 0.4 84.3 2.2 1.6 1.3 3.5

AVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line; PD = peritoneal dialysis; LTFU =lost to follow up


0 20 40 60 80 100

Leeds (124)West NI (15)

York (49)Middlbr (82)L Barts (248)

Ports (189)Nottm (79)

L Rfree (191)Liv Ain (50)

Swanse (110)L West (313)Stevng (134)Cardff (143)Dorset (72)L St.G (77)

Hull (81)B Heart (81)Redng (89)Newc (94)

B QEH (214)Prestn (118)

Salford (126)Sheff (139)Carlis (31)

Sthend (25)Derby (65)M RI (105)

Wolve (75)Chelms (46)Stoke (100)Shrew (52)

Plymth (41)Oxford (158)Bangor (21)Wrexm (42)

Brightn (121)Liv Roy (80)Exeter (127)

Donc (54)Basldn (39)Camb (93)

Newry (19)Wirral (33)Ulster (20)Truro (34)

Belfast (48)Antrim (31)

L Kings (114)Bradfd (68)Clwyd (20)Colchr (34)

Leic (156)Total (4,670)

Cent

re


TransplantedPD catheterAVFAVGTLNTL

Fig. 11.15. Type of dialysis access at three months stratified by centreAVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line; PD = peritoneal dialysis


TransplantedPD catheterAVFAVGTLNTL

0 20 40 60 80 100

Leeds (29)

L Barts (68)

Nottm (9)

M RI (34)

Stoke (19)

York (14)

Wolve (10)

Redng (25)

Shrew (40)

Ulster (11)

Truro (9)

Brightn (28)

Hull (28)

L St.G (5)

Wrexm (5)

Derby (16)

L Rfree (41)

B QEH (53)

Camb (18)

Liv Ain (6)

Plymth (6)

Ports (36)

Exeter (29)

Donc (8)

Prestn (24)

Wirral (8)

Swanse (34)

Sthend (9)

Oxford (30)

Salford (20)

L Kings (22)

Liv Roy (14)

Newc (14)

Cardff (15)

Bradfd (18)

Middlbr (20)

Sheff (29)

Stevng (34)

L West (89)

Antrim (6)

Basldn (5)

Belfast (7)

Chelms (10)

Dorset (11)

Leic (29)

Total (1,013)

Cent

re


TransplantedPD catheterAVFAVGTunnelled line Non-tunnelled line

Fig. 11.16. Type of dialysis access at three months in patients referred to renal services less than 90 days before starting dialysis, stra-tified by centreCentres reporting on fewer than five patients were excludedPD = peritoneal dialysis; AVF = arteriovenous fistula; AVG = arteriovenous graft


Whilst the reported numbers of patients presenting latetended to be low in many centres, it will be interestingto examine the practice pattern that underlies these data.

Figure 11.17 shows access in use at start of dialysis andat three months after commencing dialysis, displayed forall patients and also restricted to patients presenting late.There was a small increase in the proportion of patientsdialysing with an AVF at three months for all patients,27.8% to 33.7%. In the late presenters, patients dialysingwith an AVF, increased from 3.5% at dialysis start to 9.9%at three months. Use of a tunnelled line increased at threemonths in all patients by 14.6% and in late presenters by38.1%, which is a reflection of conversion from NTL toTL. PD catheter use saw only a small increase for allpatients (2.3%) and for late presenters (6.5%).

Figure 11.18 shows the percentage access type atdialysis start from 2012 to 2014 with the analysisrestricted to patients referred at least 90 days prior to

start of dialysis and patients who have not been trans-planted by three months. The use of an AV fistula asthe incident access dropped by 1.7% between 2012 and2014 despite the publication of the Renal Associationguidelines in 2011. Reported use of AV graft, tunnelledline, non-tunnelled line and peritoneal dialysis catheterhas been fairly static over the three-year period.

Prevalent accessNine centres did not submit prevalent numbers and six

centres were excluded from the analysis as the reportedprevalent access numbers did not match with the numberof prevalent patients at each of the centres in the UKRRdatabase.

The Renal Association guidelines on vascular access forhaemodialysis recommends 85% of all prevalent patientson haemodialysis should dialyse using an AV fistula.Only seven of the 38 centres (Birmingham Heartlands,

0

10

20

30

40

50

60

70

80

Access at startof dialysis

(5,429 patients)

All patients Late presentation

Access atthree months

(4,612 patients)

Access at startof dialysis

(1,402 patients)

Access atthree months

(1,011 patients)

Perc

enta

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f pat

ient

s

PD catheterAVFAVGTLNTL

Fig. 11.17. Access in use at start of dialysisand after three months for those still ondialysis, displayed for all patients and alsorestricted to patients presenting latePD = peritoneal dialysis; AVF = arteriovenousfistula; AVG = arteriovenous graft; TL = tunnelledline; NTL = non-tunnelled line

0

5

10

15

20

25

30

35

40

45

PD catheter AVF AVGAccess in use at first dialysis

TL NTL

Perc

enta

ge o

f pat

ient

s

201220132014

Fig. 11.18. Percentage trend in incidentdialysis access use at first dialysisPD = peritoneal dialysis catheter;AVF = arteriovenous fistula;AVG = arteriovenous graft; TL = tunnelled line;NTL = non-tunnelled line


Derby, Stoke, Truro, York, Dorset, Salford) reportingprevalent data were achieving close to the RA recommen-dations. Twenty-eight centres were more than three stan-dard deviations and three centres were more than twostandard deviations below this target (figure 11.19). Thesignificant variation between centres could be possiblydue to factors in the vascular access pathway (system fac-tors) which can be modified. Equally, there has to besome caution exercised in interpreting these results dueto non-adjustment for any of the measured and unmea-sured confounders (patient related factors) and warrantsfurther analysis.

Figure 11.20 shows type of dialysis access in prevalentpatients by centre. Variations were apparent betweencentres when considering prevalent patients with anAV fistula, ranging from less than 20% (London West)to over 65% in 13 centres. One centre had over 70% ofprevalent patients on a tunnelled or non-tunnelled line(London West) with two centres (Birmingham Heart-lands, Derby) at the other end of the spectrum with lessthan 10% of patients. The use of an AV graft was between0% and 10.8% with 35 centres opting to use this.

Use of a PD catheter in prevalent patients variedbetween 27.0% (Carlisle, Derby) and 3.7% at Middles-brough (Colchester does not have any PD patients).

Figure 11.21 shows the percentage of prevalent dialysispatients with each access type, by year. The percentage ofprevalent patients on PD has shown a decline in trend, inthe three years of the combined access audit with use ofPD declining at 1% every year. The observed fall inAVF use might be due to a different cohort of centreshaving contributed to the prevalent access data. Forexample, a large centre such as London West which has82.2% (1252/1524) of its haemodialysis patients that

dialyse via a catheter could be potentially skewing thedata.

Access failureFigure 11.22 shows comparative access failure for

the different access types within three months of start.Access failure was defined as a documented date offailure/discontinuation recorded within three months ofstarting dialysis unless a centre comment indicated thatit was a planned discontinuation. However there weredeficiencies in the way that failure was recorded in thisaudit. Failure rates were generally higher in the peritonealdialysis group with fairly similar failure rates betweenopen surgical and percutaneous at 10%. Failure rateswere generally around 5% for AVF and AVG demon-strating its superiority with failure rates for tunnelledline similar to PD (close to 10%).

The number of HD access failures reported were small.This may reflect poor local documentation proceduresand these data are not included in this report.

Again, numbers of PD access failure were small andhence drawing any inferences is difficult. However, itcan be seen from figure 11.23 that peritoneoscopic tech-nique had one documented failure within three months.As previously mentioned, percutaneous technique hadfairly comparable failure rates compared to either opensurgical or laparoscopic technique. There was no evi-dence to suggest differences in failure rates due to leaksor hernia between the different insertion techniques.Twelve out of 941 (1.3%) PD patients were reported asfailure of PD due to infection with no obvious differencein infection rates between the different PD insertion tech-niques. This was significantly lower than the nationaltarget of 5%.

2013 PD access audit one-year follow-upCentres who reported on PD patients in the 2013 vas-

cular and peritoneal access audits were asked to completea one year follow up of their PD patients. The additionalinformation requested was the date of catheter failure, thereason for catheter failure, the number of catheters usedduring the year, and the modality in use at one yearafter starting PD. Of 57 centres who reported data onPD patients in 2013, 32 completed the one year followup, returning data on 753 (73.7%) patients. Plymouthwas excluded from analysis due to over 50% missingdata. The analysis therefore included 719 patients from31 centres. In these patients, 402 (55.9%) were still onPD at one year with 87% of these (280/322) still ontheir first catheter.

Number of HD patients at centre

Perc

enta

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f pat

ient

s

0

20

40

60

80

100

0 200 400 600 800 1,000 1,200 1,400 1,600

Solid lines show 95% limitsDotted lines show 99.9% limits

Fig. 11.19. Funnel plot of the percentage of prevalent HDpatients dialysing using an AVF


Carlis (97)

Derby (334)

Wolve (386)

Stoke (424)

Redng (371)

Wrexm (143)

Hull (399)

L Barts (1,187)

Exeter (509)

Salford (515)

Nottm (443)

York (176)

L Rfree (857)

Bangor (99)

Dorset (315)

Chelms (164)

Oxford (541)

Newry (106)

Shrew (215)

Cardff (573)

Donc (212)

B QEH (1,099)

Brightn (505)

Leic (1,021)

Truro (186)

Ports (723)

Leeds (582)

Sheff (664)

Wirral (233)

Bradfd (238)

B Heart (408)

Belfast (200)

Sund (248)

Ulster (104)

Stevng (484)

L West (1,590)

Middlbr (352)

Colchr (120)

Total (16,823)

Cent

re


PDAVFAVGTL/NTL

Fig. 11.20. Type of dialysis access in prevalent patients stratified by centreCentres are ordered by the percentage of patients starting dialysis with a PD catheterAVF = arteriovenous fistula; AVG = arteriovenous graft; TL = tunnelled line; NTL = non-tunnelled line; PD = peritoneal dialysis


PD catheter AVF AVGAccess type

TL/NTL

Perc

enta

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f pat

ient

s

70

60

50

40

30

20

10

0

201220132014

Fig. 11.21. Percentage of prevalent dialysispatients with each access type, by yearPD = peritoneal dialysis catheter;AVF = arteriovenous fistula;AVG = arteriovenous graft; TL = tunnelled line;NTL = non-tunnelled line

Laparo-scopic

Opensurgery

Percuta-neous

Peritoneo-scopic

AVF AVG TL NTL

PD catheter insertion technique Type of haemodialysis vascular access

Perc

enta

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f pat

ient

s

30

25

20

15

10

5

0

Fig. 11.22. Percentage of patientsexperiencing failure of first access within threemonths, by type of first accessAVF = arteriovenous fistula; AVG = arteriovenousgraft; TL = tunnelled line; NTL = non-tunnelledline; PD = peritoneal dialysis catheter

0 20 40 60 80 100Percentage of access failures

Cath

eter

inse

rtio

n te

chni

que

Peritoneoscopic (1 failure)

Percutaneous (31 failures)

Open surgery(direct visualisation)

(43 failures)

Laparoscopic (24 failures)

Infection relatedLeaks/herniaOtherSolute/water clearance

Fig. 11.23. Reported causes of peritonealdialysis access failure within three monthsstratified by catheter insertion technique


There was a significant variation in PD technique sur-vival with the majority of centres (n = 21) maintaining550% of patients on PD at one year, however only onecentre maintained 580% on PD at one year (York).Although in general where it is particularly low,transplantation seems to be the main beneficiary withvariation between centres ranging from 0% to 42.9%.Having censored for transplantation the proportion ofpatients who were on PD was 66.1% with 28 centresmaintaining 550% of patients on PD at one year.Modality change to haemodialysis varied from 0%(Middleborough, Swansea) to .25% (BirminghamHeartlands, Sheffield, Doncaster, Dorset, Sunderland,Leeds) (figure 11.24).

Causes of PD access failure within one year of startingon PD were analysed. There was no evidence to suggest adifference in the PD failure rates when analysed by percu-taneous and all of the three other techniques combined.The reported numbers were too low to draw firm con-clusions (n = 152). Unsurprisingly the principal causesof catheter failure were mechanical or infection related(figure 11.25).

Figure 11.26. is a funnel plot which graphically dis-plays the unadjusted percentage of PD patients experien-cing a catheter failure within one year of commencementof RRT across multiple renal centres. PD catheter failurewas censored for transplantation, elective transfer to HDor death. The results have to be cautiously interpreteddue to the extent of and variation in missing data,small numbers of patients in some centres and non-adjustment for any patient related factors.

Of the centres for which data were available (n = 27),no outlier centres were identified with failure rates above

the upper 95% ‘alert’ or 99.9% ‘alarm’ limits for PDcatheter failures. Two renal centres reported one-yearcatheter failure rate below the 99% control limit (Truro,Bradford). The mean one-year catheter failure rate was

0 20 40 60 80 100

York (5)Salford (28)

Wrexm (10)Wolve (34)

Oxford (39)Swanse (18)L Barts (66)Exeter (20)

Leic (25)Truro (11)

Hull (24)B QEH (37)Stoke (31)Donc (15)

Prestn (25)Brightn (32)

Wirral (17)Dorset (23)

Basldn (8)L Rfree (56)Chelms (8)Cardff (29)Redng (33)

Middlbr (12)Sheff (25)

Leeds (18)Carlis (13)

Sthend (8)B Heart (21)Bradfd (12)

Sund (7)Total (719)

Cent

re


PDTxHDNoneDiedMissing

Fig. 11.24. Modality at one year after commencing PD, by centrePD = peritoneal dialysis catheter; Tx = transtplated; HD = haemodialysis

0 20 40 60 80 100

Laparoscopic(107 patients – 21 failures)

Open(303 patients – 64 failures)

Peritoneoscopic(31 patients – 6 failures)

Percutaneous(163 patients – 36 failures)

Missing(149 patients – 25 failures)

Cath

eter

inse

rtio

n te

chni

que

Percentage of access failures

Infection relatedCatheter relatedLeaks/herniaUnknown

Fig. 11.25. Causes of PD access failurewithin one year of PD catheter insertion


20.2% which all but met the rate recommended in theguidelines issued by the RA (20%).

Conclusions

This third multisite dialysis access audit from England,Wales and Northern Ireland has provided importantinformation regarding the variation in access provisionand failure. Data collection is still not optimal, as missingdata across a range of fields exist.

Haemodialysis catheter (TL, NTL) use continued toremain high in incident and prevalent haemodialysispatients. In incident dialysis patients, tunnelled lineswere used in approximately 41% of patients threemonths’ post dialysis start and this figure was higherfor patients presenting late. Particularly in the late pre-senters, this report highlights an opportunity for use ofpercutaneous PD access technique in order to increasethe uptake of PD and reduce catheter use.

This audit has shown that age had a bigger impact onthe type of vascular access but not on PD access witholder patients more likely to start dialysis with an AVFand less likely using a tunnelled line. This data is contraryto what has been published in the literature with theHEMO study showing a lower likelihood of having afistula in the elderly (37.5% in ,65 years vs. 27.8% in.65 years; OR 0.64, 95% CI, 0.52 to 0.79) [3]. The distri-bution of patients starting RRT in the 2014 incidentcohort was 46.6% vs. 53.4% in the under 65’s and over65’s respectively when compared to 64.7% vs. 35.3% inthe HEMO study. Hence the above observation in theaudit could be down to elderly patients more likely tostart RRT on haemodialysis via an AVF when compared

to the younger patients who have a higher likelihood ofstarting with a transplant and may use haemodialysisvia a catheter as a bridge to transplantation. Patientswith polycystic kidney disease were more likely to startHD with an AVF and demonstrate the effect of PKD asa marker for planned care, as these patients are oftenknown to renal services for many years before dialysisis required.

An interesting finding from the vascular access auditover the last couple of years has been the relationshipbetween BMI and AVF rates. The 2013 and 2014 auditshave shown that there were a higher proportion ofpatients starting haemodialysis on an AVF in the BMI.30 category when compared to the BMI 430 groupwith a difference of 12% between the two groups (audit2013: 54.9% vs. 42.6%; audit 2014: 48.9% vs. 36.8%) [4].There has been conflicting evidence in the literature,with the HEMO study showing a lower likelihood ofhaving a fistula (adjusted odds ratio 0.76, 95% CI, 0.65to 0.87) [3]. On the other hand, recent studies haveshown that obesity may not be associated with increasedfailure rates except at the highest BMI quartile and withthe use of peri-operative vein mapping similar successmay be achieved in the higher BMI group [5, 6].

Several guideline statements such as the US FistulaFirst Breakthrough Initiative, NKF-KDOQI (NationalKidney Foundation Kidney Disease Outcomes QualityInitiative), and European Renal Best Practice (ERBP)Guidelines) strongly promote the use of arteriovenousfistulae (AVF) and discourage the use of catheters(CVC); with UK Renal Association recommendationsfor a centre to achieve AVF in .65% of the incidentpatients and over 85% in prevalent patients [1, 7–9]. Afew centres have demonstrated that these targets areindeed achievable; the majority of these centres haveimplemented local quality improvement projects directedat the vascular access pathway. The differences in AVFuse in both incident and prevalent patients may be dueto variation in local processes for access planning anddelivery which needs further investigation.

This audit has highlighted that there has been a fall inthe AVF rates both in incident and prevalent patients.There is also a significant disparity between the datafrom this audit and the DOPPS data with regards toprevalent haemodialysis access, with audit data showingAVF 65.4%, AVG 4.1% and catheter 30.5% respectivelywhen compared to the DOPPS 4 data for the UK showingAVF 75%, AVG 6.6% and catheter 18.5% [10–12]. Thevascular access tariff returns have also suggested aAVF/AVG rate of approximately 75%. The reason for

60

50

40

30

20

10

00 20 40 60

Number of patients with data in centre

Perc

enta

ge o

f pat

ient

s

Dotted lines show 99.9% limitsSolid lines show 95% limits

Fig. 11.26. Funnel plot of the percentage of PD catheter failureswithin one year of insertion


this disparity is likely to be due to sampling errors. Firstly,DOPPS only samples 20 UK centres and secondly, due toa slightly different group of centres contributing to thedata in this year’s and in previous years’ data UKRRreturns.

The latest Renal Association vascular access guidelinespublished in May 2015 reduced the targets to 60% of allincident patients commencing planned haemodialysisvia AVF/AVG and 80% of all prevalent dialysis patientsshould dialyse via definitive access AVF/AVG/PD [13].The reduction in targets were intended to encouragemore centres to dialyse their patients using definitiveaccess rather than to make it easier for the centres toachieve the new targets. These targets have not beenused in the funnel plots since they were published inthe period not covered by the report. Despite the revisedtargets most renal centres continued to fall significantlybelow the recommendations. There needs to be a con-solidated effort from all specialties that are involvedwith provision of vascular access if the vascular accessstandards are to be achieved.

This audit has shown that in many centres percuta-neous insertion of PD catheters is not used at all or isunderutilised with 42% of the centres using this tech-nique. However, in those centres using the physicianled percutaneous insertion technique, 68% of them hadover a fifth of their incident patients starting on PD.The audit data has also shown that patients who werefirst seen by a nephrologist ,90 days before startingRRT, were more likely to undergo percutaneous insertionwhen compared to patients who were known between90–365 days and .365 days. Therefore, some centresthat are unable to place PD access in their unplannedstarts probably resort to TL use, clearly this pathway isunresponsive and presents an ideal opportunity for apercutaneous initiative in order to increase PD uptake.Centres with a successful percutaneous PD pathway(Derby, Stoke, Southend, Wolverhampton), were able toachieve less than 40% catheter use (TL/NTL) in theirincident patients when compared to a national averageof 51%. Therefore, in centres with low PD penetrance asuccessful percutaneous pathway at those centres mighthave a big impact on PD uptake and reduce TL use.Another important point noted in this audit is thatmany centres rely only on one technique, usually ageneral surgical approach, which may limit responsive-ness to PD. Several studies have demonstrated equivalentoutcomes between percutaneous and surgical insertion[14–16]. Hence, the use of the percutaneous techniquepathway whilst being safe, might have a better impact

on achieving responsive PD access service. The work ofCastledine et al has shown that in the UK, PD accessuse is multifactorial and depends not only on the easeof PD catheter placement but also individual patientcharacteristics and is also associated with modifiablecentre factors [17]. Therefore, improving the ease of PDcatheter placement via implementation of percutaneousinsertion technique in more centres might help to getover the first hurdle towards improving the uptake of PD.

The audit has shown that without surgical assessment,patients are more likely to require temporary haemo-dialysis access such as a tunnelled or non-tunnelleddialysis catheter. Timely surgical assessment is a keycomponent of the clinical pathway to fistula placementwhich usually leads to a successful procedure followedby successful cannulation. The other improvementsidentified by the DOPPS practice patterns were betterprevalent AVF rates, better skilled surgeons, quickerreferral to operation time and earlier cannulation [12,18]. The relationship between surgical assessment andAVF formation was very different from that of PDcatheter placement. It is quite possible that the timerequired to plan PD catheter placement is shorter becausethere are fewer steps on the PD pathway compared to thatrequired for AVF formation. For instance, the need forvein mapping may influence the timing of AVF place-ment. Many of the centres that are not able to arrangetimely surgical review resort to TL, this presents anopportunity to recommend percutaneous PD access toavoid complications related to the use of haemodialysiscatheters.

This audit has also shown that both AVF and the PDcatheter offer similar sustainability in terms of access atthree months. Percutaneous PD catheter technique hadsimilar failure rates to the other techniques combinedand hence is a recommendable technique that shouldbe better exploited.

Several DOPPS studies looked into understanding thevariation in provision of vascular access. In these studies,time to surgery, cannulation and willingness to take onmore difficult cases came out as very powerful factors[12, 19]. Similarly, the UKRR needs to firstly consider, asurvey of the practice patterns and staffing for provisionof vascular and PD access, in all the renal centres toexplore the reason behind the wide variation in haemo-dialysis access provision between centres which couldlead to potential improvements in access service pro-vision. Secondly, using statistical techniques such asInstrument Variable (IV) analysis to explore variationsin centre level survival stratified by AVF rates at the


centres with adjustments made for the captured practicepatterns at the centre along with comorbidity, ethnicity,and deprivation. This approach is the subject of the UKPD Catheter Study (UKCRN ID 17940) [20].

Similarly, it would be valuable to undertake a casestudy exploring the role of percutaneous PD catheterinsertion for primary access comparing high performingwith low performing centres to understand differences inpathways of care. This presents a quality improvementopportunity in line with recommendations from CG125(NICE technology appraisal) with the potential toincrease PD uptake and reduce TL use with beneficialeffects on MSSA bacteraemia rates and cost.

In summary, 100 percent coverage and better datareturns in the subsequent audits from all renal centres

is needed. There were still significant variations betweencentres in provision of dialysis access in patients withestablished renal failure. Further work is needed toexplore the reasons behind these variations in order todefine the best practice.

Acknowledgement

Thanks are expressed to all renal centres for theirassistance in providing the data.

Conflicts of interest: the authors declare no conflicts of interest

References

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Documents

UK Renal Registry 18th Annual Report: Chapter 11 2014 ... · UK Renal Registry 18th Annual Report: Chapter 11 2014 Multisite Dialysis Access Audit in England, Northern Ireland and